The Manhattan endoscopy center where Joan Rivers stopped breathing during what was supposed to be a routine EGD made a series of egregious errors, including letting a doctor without privileges perform a procedure Ms. Rivers didn't consent to, failing to keep proper records about how much propofol she received and snapping cellphone photos of the 81-year-old comedian while she was unconscious, according to a scathing report federal health investigators released yesterday. Among the missteps cited in the federal Department of Health and Human Services report:

Informed consent. Ms. Rivers had only consented to an upper endoscopy, but according to the investigation, an ear-nose-throat specialist "who was not a member of the medical staff and was not privileged at the facility" performed 2 different nasolaryngoscopies, one before the planned endoscopy and one after it. The ASC did not obtain an informed consent from Ms. Rivers for a nasolaryngoscopy.

Credentialing. Yorkville didn't have a process in place to ensure that only authorized personnel were permitted in the procedure room and that only credentialed physicians can perform procedures. The doctor without privileges at the clinic is believed to be ENT surgeon Gwen Korovin, MD, Ms. Rivers's personal otolaryngologist. Dr. Korovin is said to have declared "I'll go first" as she stepped into the operating room with gastroenterologist Lawrence Cohen, MD, the report says. Dr. Korovin reportedly performed the procedure in front of Dr. Cohen, the clinic's medical director, an anesthesiologist and a technician. Dr. Korovin was noted in Ms. Rivers's medical records as a "referring physician," the report states.

Time out. The endo clinic failed to take a time out before each procedure.

Cellphone photos. Investigators believe that Dr. Cohen, who is no longer working at Yorkville Endoscopy, took a cellphone picture of Ms. Rivers while she was under anesthesia, alongside Dr. Korovin, who reportedly said "maybe (Ms. Rivers) would like to see this in the recovery area."

Propofol. There was no record that staff at the center weighed the comedian before administering propofol. What's more, the report shows there were inconsistencies recorded in the dosing of the drug. The clinic's electronic record shows Ms. Rivers was given 300 mg, a huge dose of propofol. The clinic's anesthesiologist told investigators this was a mistake inputting the dose and that only 120 mg was administered.

Vital signs. The report added that Drs. Cohen and Korovin failed to detect Ms. Rivers's deteriorating vital signs, including plummeting oxygen levels, and provide timely intervention after her blood pressure had plunged to 85 over 49 and no pulse was recorded. There was conflicting information in the medical record regarding the time resuscitation was initiated and the overall management of the patient during the code. There were 2 code records in the medical record. One indicated Mr. Rivers went into cardiac arrest at 9:28 a.m. and cardiopulmonary resuscitation was initiated at 9:30 a.m. This record notes that the first set of medications, Epinephrine 1 mg and Atropine 1 mg, were administered at 9:38 a.m.

The Department of Health and Human Services has given Yorkville Endoscopy until Jan. 7 to correct deficiencies to avoid losing Medicare accreditation. In a statement, Yorkville says it has submitted a corrective plan to state and federal accreditation agencies. It says Drs. Cohen and Korovin no longer provide services there. It adds that the clinic remains open and is still fully accredited. "Yorkville has been fully cooperative and collaborative with all regulatory and accreditation agencies. In response to the statement of deficiencies, Yorkville immediately submitted and implemented a plan of correction that addressed all issues raised. The regulatory agencies are currently reviewing the corrective plan of action and have been in regular contact with Yorkville. In addition, the physicians involved in the direct care and treatment referenced in the report no longer practice or provide services at Yorkville. Yorkville will continue its commitment to complying with all standards and accreditation requirements."

Dan O'Connor